​Gerald Kominski is the director of the UCLA Center for Health Policy Research. In this brief interview, Kominski talks about ongoing threats to the Affordable Care Act, looks back at key health events this year, looks forward to policy issues that consumers face in 2016, and discusses the Center's holiday appeal.

Q: What were the biggest health policy successes this year?

T​wo things in particular made it a watershed year: In June, the U.S. Supreme Court upheld the legality of federal subsidies for qualifying people who want to buy health plans on the federal marketplace ― one of the pillars of the Affordable Care Act (ACA) ― keeping health care more affordable for millions of Americans. In October, Governor Brown signed SB 4, which next year will extend full Medi-Cal benefits to undocumented immigrant children under age 19 in California.

Q: What are some of the biggest health policy issues we face next year?

​The Affordable Care Act has helped 17.6 million people across the country gain health coverage; but the law is still under attack, and we need to protect it. If anything, we need to expand the law. According to the Kaiser Family Foundation, more than 32 million nonelderly adults in the United States ― including millions of undocumented immigrants ― still lack access to the most basic preventive care.

Even people with health coverage face unexpected health barriers: "surprise" billing practices by hospitals and health providers, some overly narrow provider networks, skyrocketing prescription drug costs. There are still disparities in health care for those with coverage: In California, our research reports Medi-Cal recipients were sometimes refused care or had less access to care than those with employer-sponsored plans. Legislators, health insurers, doctors ― and patients themselves ― need to recognize and address these problems.

Health insurers exiting smaller ACA marketplace regions or leaving the program entirely is a continuing concern, as are legislators who are trying to dismantle Medicaid expansion in their states. We continue to make great strides in California, but health reform is an ongoing challenge.

Q: The Center just sent out an appeal for funding ― what will the funds do?

​Not many people know that the Center raises all its own money. So we need all the help we can get to continue our mission of providing evidence-based research that helps legislators, health advocates, academics and media identify, understand, explain and tackle the most critical health policy issues. Your support keeps the lights on, it powers our nationally-renowned survey, the California Health Interview Survey, it helps us to develop cutting-edge products like AskCHIS Neighborhood Edition, which enables you to look at health statistics in your ZIP code and legislative district. Our data and research are used throughout the state, nation and world to fight injustices and ensure that everyone has access to health care as a basic human right. I can’t think of too many other policy centers in the nation that match us both in the size of our impact and the scope of what we examine. Take a look at our milestones page or view our latest publication, CHIS Making an Impact ― 2015, to get a sense of how our work has been used to create change.

And join us. By donating to the UCLA Center for Health Policy Research, you're not just investing in an organization – you’re investing in the future of health.

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​Gerald Kominski is the director of the UCLA Center for Health Policy Research and co-author of a new policy brief on the share of taxpayer dollars that are spent on health care expenditures. In this brief interview, Kominski discusses how tax exemptions for employer-sponsored health insurance premiums benefit the rich more than the poor, why California's share of Medicaid spending is 10 percentage points higher than the national average, and why a streamlined single-payer system might be preferable to the nation's current "crazy patchwork" of health care financing.

Q: California spends money on health care in a variety of ways, including through tax exemptions for employer-sponsored health insurance premiums. Can you explain how this works ? or does not work?

​The premiums that employers and workers pay for employer-sponsored health insurance (ESI) are exempt from taxation. These "foregone" taxes deduct $10.9 billion annually from the state coffers that could be spent on state programs like Medi-Cal and Healthy Families. Nationally, ESI tax subsidies are the third-largest health care program after Medicare and Medicaid, according to the National Bureau of Economic Research. And the ESI exclusion doesn't help low-wage workers much -- it benefits those with the highest incomes who have the most generous health plans. More than anything, the tax exempt status of ESI seems like an inefficient way to finance employer-based insurance.

Q: California's share of Medicaid spending is 10 percentage points higher than the national average (27% versus 17%). Why is this?

​Almost 33% of the population in California is enrolled in Medicaid, which is notably higher than average enrollment across the U.S. California has done a much better job at enrollment and has embraced the Medicaid expansion under the ACA. The major disadvantage of having a higher share of public spending in California for both Medicaid and total health spending is that there are fewer funds provided by private insurers. This creates pressure on providers to compete more intensely for a smaller share of privately insured patients, because they are generally the most profitable.

When providers select patients based on their profitability, we find greater disparities in access at a time when we are trying to reduce and eliminate disparities by expanding public insurance programs. This isn't a problem California can solve on its own, unless the state applies for a federal waiver to develop a single-payer system that puts everyone on equal footing.

Q: Does the current system of multiple health care programs and health-related tax incentives make sense?

​Despite the great successes of the ACA nationally and in California, our findings focus attention once again on the crazy patchwork of health care financing we have in the U.S. I believe that Sen. Sanders's campaign pledge of Medicare for All resonated with so many because it acknowledged a simple truth that most people understand intuitively; namely, that not only should everyone have health insurance, we shouldn't have significantly different health care options for the poor, for seniors, and for the working population. Far from creating "one size fits all" as critics also complain, it is possible to design a single-payer system in the U.S. that provides multiple options, subject to minimum benefit requirements that guarantee a floor for everyone.

Now that we have health insurance exchanges as a result of the ACA, maybe ACA 2.0 should find a way to move ESI, Medicare Part C, and Medicaid eligible populations into those exchanges so that insurers are required to compete for all categories of insurance, not just those they find most profitable.

Or, if insurers like Aetna don't really want to sell health insurance, it might be time to pull the plug on this grand 87-year "experiment" with trying to make private insurance markets work, and finally admit once and for all, that in this sector of the economy, government really is the best choice for financing everyone's health care.

​Gerald Kominski is the director of the UCLA Center for Health Policy Research, which recently partnered with Prevention Magazine on a survey of attitudes toward health insurance in the U.S. In this brief interview, he discusses survey results ― showing 9 in 10 respondents are satisfied with their health plans ― and what can be done to rein in costs outside of the ACA as the incoming administration discusses how to "repeal and replace" the law.

Q: What does the survey reveal in terms of feelings about the Affordable Care Act?

​There's been a lot of misinformation about how people feel about the Affordable Care Act (ACA). The survey we conducted shows that people are satisfied or even very satisfied with their coverage and want to keep their current health plan.

There are concerns about costs ― but the overwhelming message seems to be that Americans do not perceive their health care system in need of a radical change along the lines of what is being proposed by the incoming administration.

Q: Does the survey reveal concerns about cost?

​Yes, and affordability has been an ongoing concern of Obamacare. But affordability will be a concern no matter what plan is in place because health care spending isn't effectively controlled by insurance companies, and the incentives for providers to control spending are weak or nonexistent. Everyone wants health care to be cheaper, but don't want to give up anything to keep spending under control. You know the saying, having your cake and eating it too!

Further, Obamacare would be much MORE affordable if important stronger penalties for remaining uninsured had been enacted, and if more generous subsidies were available even higher up the income ladder. Or, if federal reinsurance of high-cost patients was a permanent program rather than a temporary program that phased out this year just in time for the Presidential election, which once again brings more negative attention to the ACA.

Q: Outside the ACA, what can be done to rein in costs?

​This is this issue that still hasn't been faced by U.S. policymakers or the general public. In fact, we are in massive denial about real solutions.

We can either have broad, unlimited access to every innovation, regardless of cost; low copayments and deductibles; freedom for doctors, hospitals and pharma to bill whatever the market will bear; and accept that this is the price we have to pay for unregulated markets while we also complain about the high cost of insurance and health care. Or, we can recognize that unlimited health care might be too expensive, that providers don't face real price competition in most markets because they have monopoly power, and that insurance needs to have incentives to identify and pay for value rather than volume.

Repealing Obamacare, and creating Medicaid block grants Medicare vouchers are just convenient mechanisms for limiting federal government expenditures; these policies do nothing to rein in costs. But for the immediate future, national policy is going to focus exclusively on cutting federal health spending, not controlling overall health costs.